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Religious Struggle and Its Impact on Health: Implications for Ministry. George Fitchett December 2006. Outline. Definition Evidence from Research harmful effects prevalence determinants Screening Case Examples Implications for Spiritual Care. Religious Struggle.

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Religious Struggle and Its Impact on Health: Implications for Ministry

George Fitchett

December 2006

  • Definition
  • Evidence from Research
    • harmful effects
    • prevalence
    • determinants
  • Screening
  • Case Examples
  • Implications for Spiritual Care
religious struggle
Religious Struggle

A woman in her fifties with advanced cancer told a chaplain,

“Why? Why me? I just can’t figure it out.

And I get so depressed that I just want to give up on life altogether, you know?

And I’m so very angry at God. So angry. I refuse to speak to Him. You know what I mean?”

what is religious struggle
What is Religious Struggle?

Religious struggle is having high spiritual needs and low spiritual resources with which to address those needs.

Religious struggle is marked by underdeveloped, conflicted, overwhelmed, or negative spirituality.

religious struggle early models
Religious Struggle: Early Models
  • Stoddard, 1993
    • spiritual concern, spiritual distress, spiritual despair
  • Berg, 1994, 1999
    • Spiritual Injury Scale
    • Spiritual distress (1978)
    • Potential for enhanced spiritual well-being (1994)
    • At risk for spiritual distress (1998)
  • Other Chaplaincy Models
    • Derrickson, 1994-5
    • Hodges, 1999
    • Wakefield & Cox, 1999
spiritual distress nanda
Spiritual Distress: NANDA


Disruption in the life principle that pervades a person's entire being and that integrates and transcends one's biological and psychosocial nature.

Related factors [etiology]

Separation from religious and cultural ties

Challenged belief and value system (e.g., result of moral or ethical implications of therapy or result of intense suffering)

Defining characteristics

Expresses concern with meaning of life and death and/or belief system

Anger toward God (as defined by the person)

Questions meaning of suffering

Verbalizes inner conflict about beliefs

Unable to choose or chooses not to participate in usual religious practices

Regards illness as punishment

Does not experience that God is forgiving

Two Year Change in Religious Struggle and Its Effects on Outcomes Among Elderly Medically Ill Patients

*Models adjusted for demographic factors and baseline values.

Source: Pargament et al, Journal of Health Psychology, 2004

conflict about prayer
Conflict About Prayer
  • Unanswered prayer (13/30)
  • Hesitancy about petitionary prayer (10/30)
  • Conflict about control (9/30)
  • Questions about the nature of God (8/30)
  • Questions about meaning and theodicy (8/30)
  • Bargaining (5/30)
  • Doubt about the efficacy of prayer (4/30)
  • Doubt about personal spirituality and worth (4/30)
  • Praying the “right” way (4/30)

20% of patients had four to six types of spiritual conflict associated with praying about their cancer.

Taylor, et al., 1999

religious struggle and emotional distress down under
Religious Struggle and Emotional Distress Down Under

36 medical/surgical patients, Melbourne; F (2,35) = 3.7, p = .03.

source ano and vasconcelles journal of clinical psychology 2005
Meta-Analysis of Negative Religious Coping and Psychological AdjustmentSource: Ano and Vasconcelles, Journal of Clinical Psychology, 2005.

Correlation Between Negative Religious Coping

And Negative Psychological Adjustment

Number Cumulative Confidence

of Studies Effect Size Interval

22 .22* .19 to .24

comfort from religion and religious struggle
Comfort from Religion and Religious Struggle

149 patients with diabetes or CHF

determinants of religious struggle
Determinants of Religious Struggle

From Fitchett et al, 2004

differences in rs by age
Differences in RS by Age

1998 GSS also found an age difference in negative religious coping (2 items, p<.05); mean scores:

< 65: 1.25

> 65: 1.18

differences in rs by gender
Differences in RS by Gender

No gender differences in GSS study.

Gender difference:

-negative religious coping, ns

-positive religious coping, t = -3.0, p=.003

isn t religious struggle really just depression
Isn’t Religious Struggle Really Just Depression?

The size of the correlations between religious struggle and depression in our study (r from 0.22 to 0.42) suggest religious struggle is associated with but cannot be reduced to depression.

Religious struggle predicts both poor recovery and mortality in models which adjust for depression.

prevalence of religious struggle
Prevalence of Religious Struggle

From Fitchett et al, 2004

prevalence of religious struggle1
Prevalence of Religious Struggle

Responses of “quite a bit” or “a great deal.”

screening for religious struggle
Screening for Religious Struggle

Screening for religious struggle is an attempt to identify patients who may be experiencing religious struggle.

Screening for religious struggle employs a few, simple questions, that can be asked by health care colleagues.

religious struggle and requests for spiritual care percent who request spiritual care
Religious Struggle and Requests for Spiritual Care(percent who request spiritual care)

Chi-square = 21.19, p <.001

From Fitchett et al, J Pastoral Care, 2000

barriers to screening
Barriers to Screening

Phase I, Patient Care Technicians

  • PCTs felt overwhelmed by other tasks and couldn’t administer the protocol because of time constraints.
  • Turnover of PCTs made follow through difficult.
  • The protocol was sometimes misunderstood and not followed.

Phase II, Medical Residents

  • The heavy Resident work load was a major barrier.
  • Turnover of Residents made consistency difficult.
  • Resident’s lack of training about the importance of spiritual struggle was a problem.
hershey medical center questions in admission assessment that trigger pastoral services referral
Hershey Medical Center: Questions in Admission Assessment that Trigger Pastoral Services Referral
others models for screening
Others Models for Screening
  • Stoddard
  • Derrickson
  • Berg
  • Hodges
  • Wakefield & Cox
  • GF Review, CT, 1999
three levels of inquiry about religion spirituality
Three Levels of Inquiry About Religion/Spirituality
  • screening for religious struggle
  • religious/spiritual history taking
  • spiritual assessment
case example alienated from religion
Case Example: Alienated from Religion

The chaplain was referred to the patient who was a candidate for a heart transplant because he appeared very discouraged. He was also receiving medication for depression.

The patient told the chaplain about a negative experience he had with a particular church and pastor. As a result of this experience, the patient was angry with God and alienated from religious institutions.

The chaplain helped the patient separate his experience with the church from his relationship with God. She helped him rebuild his relationship with God and find a new church home.

As he did these things the patient’s depression resolved and the medication was discontinued.

the case of mrs fisher
The Case of Mrs. Fisher

Mrs. Fisher was a 74 year old women with a history of toe amputation on her left foot. She had an ulcer on a toe on her right foot and had just had an operation to replace a section of the artery in her right leg.

Her doctor had recently told her that her prognosis was very good, that she would be able to do all that she had been doing prior to the surgery.

As she made a referral to the chaplain, the nurse described Mrs. Fisher as very depressed.

From: Whitby, 1999

the case of mrs fisher1
The Case of Mrs. Fisher

Chaplain: Sounds like you’re angry with God?

Mrs. F: (Looking up sharply) Yes I am.

No one has said that to me before.

Chaplain: No. Have you told Him?

Mrs. F: No. Do you think He’d listen? (Looking over her glasses challengingly.)

Chaplain: Yes. I think He would.

(Mrs. F. looked intently at the chaplain.)

implications for spiritual care
Implications for Spiritual Care
  • For chaplains
  • For other health professionals
  • For congregations
implications for chaplains
Implications for Chaplains
  • Chaplains come to term with their own religious struggles
  • Finding the Lost Sheep

“I ask God to lead me to the ones who need me.”

  • A two – step process

1. screening by healthcare colleagues

and if indicated

2. indepth spiritual assessment by a trained chaplain

  • Responsible screening and “intervention”
pastoral responses to religious struggle
Pastoral Responses to Religious Struggle
  • Assess
    • sources of struggle
    • duration: new, transient, leading to growth, chronic
    • available resources
  • Giving Voice, Being Heard
    • muteness, lament, companionship
  • Finding Meaning
    • creating a new narrative
    • creating a new future story
implications for chaplains three questions
Implications for Chaplains: Three Questions
  • How did you decide which patients to see this week?
  • How did the staff you work with determine who to refer and who not to refer?
  • What evidence did you generate this week that your ministry made a difference in measurable patient outcomes?
implications for chaplains2
Implications for Chaplains

Early identification and follow-up of patients with religious struggle may:

  • improve their adjustment
  • improve their recovery
  • reduce their risk of mortality

Documenting the prevalence of religious struggle provides a measure of spiritual acuity and a basis for determining chaplaincy staffing levels

implications for spiritual care1
Implications for Spiritual Care
  • For other health professionals
  • For congregations
    • Provide narratives and models for lament and religious struggle
    • Follow-up with lost sheep
postscript blind faith the unholy alliance of religion and medicine
Postscript: “Blind Faith: The Unholy Alliance of Religion and Medicine”

“Can You Measure a Sunbeam with a Ruler?” (Lederberg and Fitchett, 1999)

postscript blind faith the unholy alliance of religion and medicine1
Postscript: “Blind Faith: The Unholy Alliance of Religion and Medicine”

“Can You Measure a Sunbeam with a Ruler?” (Lederberg and Fitchett, 1999)

“While such measurement may be possible, it cannot capture the essence of the sunbeam and in fact may distort it” (R Sloan, 2006).

postscript blind faith the unholy alliance of religion and medicine2
Postscript: “Blind Faith: The Unholy Alliance of Religion and Medicine”

“Can You Measure a Sunbeam with a Ruler?” (Lederberg and Fitchett, 1999)

“While such measurement may be possible, it cannot capture the essence of the sunbeam and in fact may distort it” (R Sloan, 2006).

“It is our hope that the contents of this special issue will help psycho-oncologists smoothly integrate religion and spirituality into their therapeutic and research pursuits without short-changing their patients with too much uncritical enthusiasm, or too much ignorance, indifference or cynicism” (Lederberg and Fitchett).